Ocular Emergencies




(1)
Royal Free NHS Foundation Trust, London, UK

 




Causes of acute red eye

Uniocular

Painless



  • Normal vision:


  • Subconjunctival haemorrhage


  • Episcleritis


  • Pterygium


  • Pingueculum


  • Conjunctivitis

Painful



  • Normal vision:



    • Corneal stain:



      • Negative



        • Anterior uveitis (iridocyclitis and iritis) (irregular pupil from posterior synechiae, circumcorneal congestion, anterior chamber flare and cells; keratic precipitates on posterior surface of cornea)


        • Scleritis (redness of the sclera, localized or generalized; diffuse tenderness)


        • Herpes zoster ophthalmicus (early)


      • Positive



        • Corneal abrasion


        • Herpes simplex keratitis


        • Marginal ulcer


  • Vision reduced:



    • Corneal fluorescein stain negative



      • Severe uveitis


      • Acute angle closure glaucoma (circumcorneal congestion; non-reactive, semi-dilated vertically elliptical pupil; corneal oedema or haziness; shallow anterior chamber; severe pain; vomiting; haloes around lights; predisposing factors include a shallow anterior chamber, hypermetropia, and lens abnormalities such as cataracts)


      • Secondary glaucoma


    • Corneal fluorescein stain positive



      • Herpes simplex keratitis (punctate keratitis; small bullous epithelial lesions; dendritic ulcer-branching linear lesion; geographical ulcer)


      • Bacterial keratitis


      • Herpes zoster ophthalmicus: clear vesicles on inflamed and hyperaesthetic forehead, upper eyelid or on tip of nose (Hutchinson sign), in distribution of ophthalmic division of trigeminal nerve; punctate or dendritic lesions of cornea; follicular or papillary conjunctivitis; episcleritis


      • Corneal burn


      • Acanthamoeba keratitis (contact lens wearer; disproportionate pain; superficial punctuate keratitis; ring infiltrates from coalescing paracentral infiltrates; radial keratoneuritis due to infiltrates along corneal nerves)

Binocular:

No pain/good vision:



  • Bacterial conjunctivitis: purulent discharge


  • Viral conjunctivitis


  • Allergic conjunctivitis

Pain/vision good or poor:



  • Viral keratoconjunctivitis


  • Chlamydial keratoconjunctivitis


  • Arc eye (photokeratitis or ultraviolet keratitis) (pain, lacrimation, foreign body sensation, photophobia, miosis; punctate conjunctival erosions; exposure to welder’s arc, sun lamp in tanning salon or bright snow-covered environment)


Patterns of red eye

Normal/near normal vision

Painful/discomfort



  • Diffuse superficial redness of bulbar and palpebral conjunctiva, maximal in the fornices: conjunctivitis


  • Diffuse deep redness: anterior scleritis


  • Circum-limbal (corneo-scleral junction) redness: keratitis; anterior uveitis; corneal foreign body


  • Sectoral redness: episcleritis

Painless



  • Subconjunctival haemorrhage: deep crimson red and confluent

Reduced vision

Normal intraocular pressure



  • Abnormal cornosclera: corneal abrasion; keratitis


  • Abnormal uvea: anterior uveitis; endophthalmitis

Raised intraocular pressure



  • Acute glaucoma

Hypertensive uveitis

Red flags for red eye



  • Moderate to severe ocular pain


  • Photophobia


  • Marked redness of one eye


  • Loss of visual acuity


  • Associated bowel or joint symptoms

Checklist for foreign body sensation in the eye



  • Visual acuity


  • Pupil size, shape and reactions


  • Upper and lower fornices of the conjunctiva, including eversion of the upper lid


  • Fluorescein staining of the cornea; linear vertical corneal abrasions suggest a subtarsal foreign body


  • Anterior chamber: intraocular foreign body; hyphaema


Clues to cause of conjunctivitis





  • Bacterial: mucopurulent or purulent discharge


  • Gonococcal: profuse purulent discharge; severe chemosis and eyelid swelling


  • Viral: watery, mucous discharge; lacrimation; foreign body sensation; pinpoint subconjunctival haemorrhages; preauricular lymphadenopathy


  • Epidemic keratoconjunctivitis: chemosis; corneal infiltrates


  • Herpes simplex: vesicles on eyelid margin or peri-ocular skin; dendritic ulcer


  • Herpes zoster: rash or vesicles in distribution of naso-ciliary branch of ophthalmic division of trigeminal nerve; dendritic ulcer


  • Allergic: seasonal; itching, lacrimation; personal or family history of atopy


Risk factors for bacterial keratitis

Local ocular factors



  • Corneal: abrasion, foreign bodies, exposure, bullous keratopathy


  • Abnormal tear function: dry eye; dacryocystitis


  • Abnormal lid function: blepharitis; entropion; ectropion; cicatricialpemphigoid; lagopthalmos; trichiasis


  • Cosmetic: contact lens wear; cosmetic eye makeup


  • Drugs and treatments: topical corticosteroids; cyanoacrylate adhesive; ocular surgery

Systemic factors: immunosuppressive therapy; diabetes mellitus; coma; alcoholism; burns; Stevens-Johnson syndrome; AIDS


Causes of hyphaema





  • Ocular trauma: blunt; penetrating


  • Intra-ocular tumours: ocular melanoma; retinoblastoma; metastatic tumours


  • Coagulopathy: von Willebrand disease; thrombocytopenia; haemophilia; leukaemia


  • Neovascularisation of the iris: proliferative diabetic retinopathy; carotid stenosis


  • Post-surgical: cataract extraction; trabeculectomy; pars plana vitrectomy


Causes of periorbital redness and swelling

Orbital inflammation

No proptosis

Infections



  • Pre-septal cellulitis (secondary to lid trauma –e.g. insect or animal bite, minor trauma-e.g. eyelid abrasion; lid skin infections-stye, dacryocystitis, herpes simplex; conjunctivitis; associated with upper respiratory tract infections and sinusitis; normal visual acuity and pupillary reflexes)


  • Dacryocystitis (tense painful erythematous swelling below the medial canthal ligament)


  • Dacryoadenitis (painful erythematous swelling of the lateral upper eyelid, with or without ptosis)


  • Blepharitis (erythema and thickening of eyelid margins; crusting and scales, with eyelash loss; eyelashes may stick together)


  • Conjunctivitis


  • Endophthalmitis

Non-infectious causes



  • Allergic reaction

Proptosis



  • Orbital infections: orbital cellulitis (lid oedema; pain with eye movements; conjunctival hyperaemia and chemosis; ophthalmoplegia; optic nerve involvement with reduced visual acuity; fever; loss of sensation related to the ophthalmic and maxillary divisions of the trigeminal nerve; may involve spread of infection from paranasal sinuses, especially the ethmoid or frontal sinuses); cavernous sinus thrombosis


  • Endocrine: thyroid eye disease


  • Inflammatory: systemic inflammatory disorders: Wegener’s granulomatosis, sarcoidosis; orbital pseudotumour


  • Neoplasm: lymphoma; lymphoproliferative disorders; rhabdomyosarcoma; choroidal malignant melanoma with extra-ocular spread; metastatic carcinoma


  • Carotid-cavernous fistula (proptosis; conjunctival chemosis; exposure keratopathy; poorly reactive dilated mid-position pupil; retinal vein congestion; raised intraocular pressure)


  • Retrobulbar haemorrhage/abscess


Risk factors for mucormycosis





  • Diabetic ketoacidosis


  • Haematological malignancy


  • Bone marrow and solid organ transplant recipients


  • Steroid therapy


  • Intravenous drug use


  • Burns


Causes of diplopia (double vision)

Monocular



  • Extra-ocular: optical lens or contact lens problem


  • Ocular



    • Strabismus


    • Lid: chalazion


    • Cornea: infection, trauma, distortion (keratoconus)


    • Iris: pharmacological mydriasis


    • Lens: cataract; subluxation


    • Retina: detachment, central retinal vein occlusion


    • Uncorrected refractive error (resolves with pinhole testing)

Binocular



  • Cranial nerve palsies (infranuclear): III, IV, VI


  • Myopathies: thyroid eye disease; myasthenia gravis


  • Trauma: orbital blow-out fracture


  • Orbital lesions: cellulitis; neoplasm


  • Supranuclear lesions: internuclear ophthalmoplegia (horizontal diplopia with weakness of adduction of ipsilateral eye and nystagmus of the contralateral abducting eye); brainstem ischaemia (pons or midbrain lesions)


Checklist for diplopia





  • Resting position of the eyes


  • Eyelid function: ptosis


  • Visual acuity in each eye separately and then both together


  • Pupil size and reactivity


  • Ocular motility; disconjugate eye movements; nystagmus


  • Other cranial nerves


  • Cerebellar function


  • Fatigability of eye movements (myasthenia gravis)


Causes of acute visual loss

Uniocularvisual loss

Central:

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Nov 20, 2017 | Posted by in Uncategorized | Comments Off on Ocular Emergencies

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